Financial Aid and Scholarship Services
Student Services Center
525 Buena Vista SE
Albuquerque, NM 87106
505-224-3040, fax: 505-224-3124
www.cnm.edu
The Legislative Lottery Scholarship
Request for Probationary Status
The Request for Probationary Status is for students who have been unable to meet Legislative Lottery
Scholarship requirements due to exceptional mitigating circumstance beyond the student’s control. Requests
are reviewed by CNM Financial Aid and Scholarship Services. Approval may be granted to qualified students
under certain highly restrictive circumstance.
To be completed by student
Student ID: _________________________________________________________ Date: _____________________________
Name: _______________________________________________________________________________________________
Last
First
MI
Address: _________________________________________City: ______________________ State: _____ Zip: ____________
Phone Number: ________________________________________Email: ___________________________________________
High School Diploma /GED Date: _____________________ Dates you were unable to attend _____________ to ____________
Term returning to school:
Fall 20___
Spring 20___
Indicate if you are unable to attend:
Qualifying Term - first term after receipt of a New Mexico high school diploma
Subsequent term - you completed your Qualify Term successfully but are now unable to attend
Indicate the reason you were unable to attend:
Documented exceptional mitigating circumstances - Provide a personal statement detailing the circumstances
and/or medical condition that prevented you from meeting requirements for the Lottery scholarship. Medical
leave requests must include a doctor’s signed medical report stating why you were unable to attend class and
any additional supporting documentation. Other traumatic life experience must be explained and
appropriately documented.
Active-Duty Military Service – Provide a copy of your DD214 indicating your entry date of your active-duty
service and the date of your separation. Entry date of military service must be within 120 days of graduation
of high school and date of CNM enrollment must be within 1 year of separation from active duty.
Student Signature _____________________________________________
Date____________________
To be completed by Financial Aid and Scholarship Services
High School Graduation Date: ___________________________________ Term(s) Absent: ________________________________________
Documentation Provided: ____________________________________________________________________________________________
_________________________________________________________________________________________________________________
Approved:
QT 20______
1st 20_________
2nd 20_________
3rd 20_________
Denied and reason: _________________________________________________________________________________________________
_________________________________________________________________________________________________________________
FASS Signature _______________________________________________ Date ________________________________________________
01/2015
Submit this request with attached documentation to Financial Aid & Scholarship Services, SCC Main Campus